neurologic evaluation nb,infants & children

8/10/2019 Neurologic Evaluation Nb,Infants & Children

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NEUROLOGIC EVALUATIONNB,INFANTS & CHILDREN• Objectives:

1. To ascertain that the nervous system is involved and determine thepart/parts of the nervous system involved.

2. To determine if the disease process is progressive or static.



3. To determine the possible etiology of the disease process.

4. To guide the clinician in the prescription of the appropriate ancillarydiagnostic test.



Essential Components of a GoodNeurological Evaluation:• I. Complete data of the ff:

1. Birth History

* Manner of delivery and possiblecomplications

* Birth weight

* Apgar score



2. Maternal History

* Parity and Gravidity

* Maternal age* Illness and nature vs. age of conception



3. Family History

* Similar illness in the family

* Familial diseases, pedigree* Unexplained deaths



4. Developmental History

* Motor development

* Language function: verbal,nonverbal

* Social/behavior/play activities

* School performance



5. Nutritional and Feeding History

6. Past Medical History



Components ( cont.):

• II. Vital Signs and Anthropometric MeasurementsHC : rate of growth vs. growth chart

: vs. parents’ HC

HC vs. CCFontanel: ant. And post. Vs age of closure



Components of (cont):

Ht vs. Age vs. Proportion,ie arm span

III.Presence of Abnormal/Unusual Features

* Head shape

* Dysmorphisms/minor physical anomalies



* Spinal deformities/dysraphism

* Cutaneous manifestations



Head Circumference:

• A. Normal HC at birth: 33-35 cm• B. Rate of Growth ( del Mundo):

First 4 months= ½ inch ( 1.2 cm) /month

Next 8 months= ¼ inch (0.64)/mo.2nd year of life= 1 inch (2.54 cm)

3-5 years= ½ inch (1.2 cm)/yr.



Head circumference(cont):

6 th -20 th yr.= ½ inch (1.2 cm)/ 5 yrs.

Head Circumference vs. Chest C:

* HC>CC at birth* HC=CC at 6 mos.

* HC<CC at the end of first year of life



DEFINITIONS:

• Microcephaly: Head circumference less than 2 SD below the mean forage, sex and race

• Macrocephaly: Head circumference more than 2 SD above the meanfor age, sex and race.



FONTANELLES:

• A. Anterior fontanels

* closes between 7 and 19 mos of age in 90% of normalinfants

* closes by 26 mos in the rest of the normal infants

* average time of closure:16.3 mos for boys and 18.8 mos ingirls



B. Posterior Fontanel

* closed by 3 months



Neurological Exam of Infants andChildren:• MENTAL EXAMINATION

I. Level of consciousness or degree of alertness

* observe activity during waking period; in infants < 1-4mos of age

* quality of cry



Level of consciousness ( cont.):

* waking and sleeping pattern

* play activity and ability to interact with people

II. Cognitive Function:

* in infants: ability to demonstrate expected socialbehavior, i.e. regards at 2 mos,cooing at 2-3 mos., etc



Cognitive functions ( cont.):

* language function in older infants and children: i.e. basedon the language inventory chart- assess both verbal andnonverbal language function

* school performance

* behavior and play activity



Motor Examination:

• > Observation of the child in diff. postures and while at play willusually give information concerning weakness, problem in muscletone or incoordination of movements. Since it is difficult to assessindividual muscles, spontaneity of movements, handedness,

preferential posture and movements of limbs is used to assess motorfunction.



What to assess:

• 1. Expected motor development depending on age• 2. Symmetry of movement• 3. Handedness•

4. Posture• 5. Muscle tone• 6. Muscle bulk• 7. Gait



Graded Muscle Scale: BritishMedical Research Council)• 0- no muscle contraction• 1- trace• 2- active movement of joint-not against gravity•

3- active movement of joint-against gravity



Graded Muscle Scale:

• 4. active movement against resistance• 5- normal



REFLEXES:

• In infants, absence or presence of primitive and adaptive reflexes aredetermined to evaluate the level of maturity of the nervous system.

• On the other hand, the segmental reflexes of the muscle stretchreflexes and the superficial reflexes are elicited to determine location

of the lesion.



SENSORY EXAMINATION:

• Proper sensory exam is difficult if not impossible in infants andtoddlers. Cotton, the neurological hammer, or other blunt objects canbe used to elicit responses.

• Pins scare children and should be avoided.



CEREBELLAR FUNCTION:

• Observe for the following in infants:

1. posture

2. tremors during action

3. head tilt4. nystagmus

In older infants and toddlers: Observe for the above, plus:



Cerebellar function:

• 1. coordination of movements: hand patting; foot tapping, finger-to-nose test

• 2. Station and gait



AUTONOMIC FUNCTION:

• * Sweat pattern• * Toilet training vs. bowel/bladder function• * Sphincter tone



Eliciting for meningeal signs:

• Presence of meningeal signs may suggest any of the following:

1. inflammation of the meninges as in meningitis

2. presence of blood in subarachnoid

3. impending tonsillar herniation4. presence of cervical and paracervical inflammation



FUNDOSCOPIC Examination:

• * Very vital in the evaluation of children with neurologic problems• What to look for:

1. Optic discs- in infants normally pale and gray ( not optic atrophy!);obliteration of disc borders and absent pulsations of the central veinsare the earliest and most important indication of papilledema.



Fundoscopy:

• 2. Retinal hemorrhages are seen in 1/3 of vaginally deliverednewborns; usually small and multiple and do not necessarily signifyintracranial bleeding.



NEUROLOGIC EXAMINATIONOF THE NEWBORN• Differs from infant, older and adult in that, it:

> relies heavily on close observation than the usualexamination with hammer and light

> requires watchfulness and patience since most findings aresubtle



> requires appreciation of the normally rapidly evolvingbehavioral repertoire with increasing age among premature



Integral Steps in Examination ofthe Newborn:• I. Inspection at rest• II. Examination of the head• III. Arousal•

IV. Cranial nerves• V. Tone• VI. Integrated reflexes• VII. Fundoscopy



I. Inspection at rest:

• A. Search for: malformations/dysmorphisms; cutaneous stigmata;evidence of physical trauma; presence of seizures

• B. Observe resting posture (one of the more important clues toneurological status):



Resting posture:

• Normal:• 32-40 wks: some abduction of hips

: flexion of elbows, hips, and knees

: hands loosely fisted with thumboutside of other fingers, closing andopening spontaneously



Resting posture:

25-32 wks: arms flexed, legs either flexed or extended

Abnormal:

Hypotonia: frog-leg posture: legs fully abducted with lateral thighresting on supporting surface

All limbs in full extension



Hypotonia(cont):

Arms either extended or flexed at elbow but dorsa of handsagainst supporting surface and palms of hand facing upward



• Hypertonia: neck extended, limbs extended andinternally rotated

: Hands fisted with thumb constantly enclosedby other fingers and not

opening spontaneously



II.Examination of the Head:

• Palpate sutures and fontanelles gently with baby in quiet state:

> Size: mean diameter of anterior fontanelle is 2.1 for term NB,metopic and coronal sutures should not admit a fingertip.



Tension :

• Bulging: fontanelle rises above level of bone edgesand sufficiently tense to make it difficult todetermine where bone ends and fontanelle begins;

normal in vigorously crying NB; always abnormal inthe sleeping state.• Full: fontanelle distinguished from surrounding

bone edge but does not depress to palpating finger



Tension (cont.):

• Soft: fontanelle distinguished from surrounding bony edge anddepresses to palpating finger



III. Arousal

• To elicit arousal, grasp thorax between thumb and index finger andshake gently:

> opening of the eye

> facial grimacing

> crying

> movements in all limbs



Arousal ( cont.):

• Once aroused > term NB and premie at least 34 wks will remainAWAKE throughout the examination

> Prematures 28-33 wks have difficulty in maintaining alert state forlong periods

> Prematures 25-27 wks require frequent stimulation to maintainarousal



Arousal ( cont.):

• Inability to provoke at least facial grimace and movement ofextremities: ABNORMAL> decreased consciousness

• Lethargy: arousal accomplished readily but with some difficulty inmaintaining the aroused state



Arousal ( cont.):

• Obtundation: arousal accomplished by non-painful stimuli butresponse delayed, incomplete, and cannot be maintained.

• Stupor: arousal accomplished only by painful stimuli ( grimacing,generalized movement, not merely withdraw from pain)



Arousal (cont.):

• Coma: arousal cannot be accomplished by painful stimuli• Jitteriness: excessive response to arousal> low-frequency, high

amplitude shaking of limbs and jaw

: commonly assoc. with low threshold for Moro reflex

:can occur without apparent external manipulation



Jitteriness (cont.):

: can be distinguished from seizure by lack of eyemovement, lack of change in respiratory pattern, andprovocation by stimulation



IV. Cranial Nerves:

• Grimacing and crying: evaluate fullness of facial expression; withmouth open, observe tongue and palate

• Rooting and sucking: rooting response complete at 32 wks; suckingvigorous and sustained by 36 wks; partially test V,VII, XII



Cranial nerves:

• Vestibular part of VIII tested by Moro reflex



V. Tone:

• Resistance of muscle to stretch• 2 types:

1. Phasic tone- in response to short duration, high amplitude stretch;assessed by testing resistance of limbs to movement and by activityof tendon reflexes



Tone:

Decreased tone: decreased resistance ; non-specific finding inneonates with cerebral depression, spinal injuries, motor unitdisorders systemic illness

Tendon reflexes:

Patellar reflex: only tendon reflex consistently present at birth



Tone: ( tendon reflexes):

• Absent tendon reflexes: dysfunction of motor unit/acuteencephalopathy

• Ankle clonus: a few beats maybe normal in neonates, but sustainedclonus is abnormal; can be present in acute encephalopathy when

knee jerk is absent



Tone ( cont.):

• 2. Postural tone: in response to sustained low amplitude stretchimposed by gravity

3 tests of postural tone performed in sequence:

1) traction response: most sensitive

: initiated by placing examiner’s index fingers in child’s hands toprovoke a grasp reflex



Postural tone:

• Normal response:

> head lags minimally> becomes erect momentarily>may fall forward

Hypotonia: more than minimal headlag and full extension of arms interm NB

2) Vertical suspension: place hands in axillae without grasping thoraxand lift straight up



Vertical suspension( cont):

• Normal response:

> arms press down on examiner’s hands > allows NB to be suspendedvertically

> head erect in midline briefly

> legs flexed at hips, knees, ankles



Postural tone:

• Abnormal response:

>head, body, limbs hang down limply with little or no resistance togravity



VI. Integrated Reflexes:

• The Moro Reflex:with NB in supine position, head is allowed to fallrapidly but gently a few centimeters in the examiner’s hands

Normal response: arms abducted and extended, hands opened, armsabducted and flexed, fists closed

Abnormal response: complete absence of abduction and extension



Integrated reflexes:

• The Tonic Neck Reflex: NB in supine position withhead in midline; turn head slowly to right andobserve position of upper extremities. Do the same

to the left.Normal response: with head turned to R, increasedextensor tone in R arm and flexor tone in left arm(fencing position); same reaction when head is

turned to L



Abnormal response: excessive and obligatory; whenunilateral, indicate brain damage in the hemisphereopposite the extended limbs.

The Withdrawal Reflex: prick sole of foot with sterileblunt objectNormal response: flexion movement of stimulatedlimb and extension/flexion of contralateral side



Abnormal: absent flexion of stimulated leg( motor unit disorder)

Present at 28 wks gestation

Probably integrated at spinal level

Positive in newborns with cerebral palsy



VII. Ophthalmoscopy:

• Some tips to facilitate examination:

> NB is given nipple to suck, placed in prone position with left side offace resting on surface to examine left eye> most NBs open their eyesin this position

> Avoid touching child’s face/eye! will cause immediate closure of lid

neurologic evaluation nb,infants & children

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